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Home , Inalienable possessions, Marcel Mauss, The Gift (essay)

Repaying and Cherishing the of Life: Gift Exchange and Living-related Kidney Transplantation in the Philippines

Yosuke Shimazono

Abstract: This paper considers living-related kidney transplantation, especially that between family members in the Philippines. Drawing on the anthropological theory of gift, it explores two aspects of relationship—the relationship between the do- nor and the recipient and the relationship between the recipient and the object—and describes two categories of acts—‘acknowledging the /repaying the gift of life’ and ‘taking care of a kidney/cherishing the gift’. This paper seeks to show that there is an internal tension in live kidney transplantation between two rival principles of gift operative in the world of Filipino family and : one akin to the Maussian or ‘ar- chaic’ gift and the other that places cherishing of the gift over repaying of the debt.

Keywords: ‘archaic’ gift exchange, family, gift, kidney transplantation, , Philippines

In his seminal essay, The Gift, Mauss attempted is to make a present of some part of oneself’ to unravel the common principles running (1990: 16). The objects given are typically the through gift exchange practices in important substance and being of the indi- which he termed ‘archaic’—Melanesia, Poly- vidual and/or group. Even after being given nesia and the Pacific Northwest (Mauss 1990). away, they still bear the ‘stamp of those who According to Mauss and his successors, gift possessed it previously’ (Carrier 1994: 25). exchange as practised in these societies was According to Weiner and Godelier, they are characterised by two major elements that are ‘’, which cannot com- intertwined: the obligatory transfer of the ob- pletely be alienated; the original owner retains ject and the inalienability of the object. inalienable (Godelier 1999; Weiner Firstly, the giver and the receiver of ‘archaic’ 1992). Mauss’s exposition of the ‘archaic’ gift are bound by a moral obligation to give, provides us with an important platform for an receive and repay, although these acts may be anthropological investigation on organ trans- spontaneously fulfilled or performed with the plantation. This is because, as an internal part attitude of generosity. It is well known that of the body, human visceral organs resist the Mauss singled out the obligation to repay as dichotomy of the ‘person’ and the ‘thing’ and the most important obligation, as it acts as a appear to be ‘part of the person’ as well as part hinge for propagating the circuit of gift-giving. of the body. Secondly, the object transferred through this The aim of this paper is to consider living- kind of gift exchange is inalienable. In Mauss’s related donor kidney transplantation in the term, ‘to make a gift of something to someone Philippines in the light of the anthropological

Anthropology in Action, 15, 3 (2008): 34–46 © Berghahn Books and the Association for in Action doi:10.3167/aia.2008.150304 Repaying and Cherishing the Gift of life | AiA

theory of the gift. Focusing on cases of live of stewardship over the object given overshad- kidney transplants between family members, ows the norm of reciprocity. I explore the gift relationship between the recipient and the donor. More specifically, I address the following issues. What kind of gift Organ transplantation and the is the donation of kidney from a living family anthropology of the gift member to another? What kind of relationship does this unique form of gift object create? Does organ transplantation have something in What kind of obligation does this gift engen- common with ‘archaic’ gift exchange depicted der? How is this object treated after it has been by Mauss? From one viewpoint, deceased transplanted? donor organ transplantation seems to be even My fieldwork was carried out for 18 diametrically opposed to the Maussian gift months between June 2004 and December exchange. Deceased organ donation may be 2005. It consisted of characterised as the ‘modern’ gift, not only of the activities of the Kidney Transplant for the obvious reason that this form of gift is Association of the Philippines (KITAP) and made possible by modern medical technology, interviews with its members. KITAP is an as- but also because of the moral and legal rules sociation of ‘kidney transplantees’ or people pertaining to it.1 who have undergone kidney transplantation. Just like blood donated to the British Na- Established in 1984, the KITAP has over 1,500 tional Health Service (NHS), deceased organ members, and organises activities, such as donation is supposed to be nonreciprocal and Patients’ Forum, Kidney Transplant Anni- ‘free’; the donor, who is expected to act out versary Celebration and Philippine National of ‘’, will not receive any countergift Transplant Games. In total, I interviewed and the recipient has no reciprocal obligation 53 transplantees, of whom 22 had received to the donor. This gift-giving is also seen as kidneys from a sibling, parent or child; this a charitable act, directed to an anonymous particular group of interviewees forms the stranger. The giver is an individual citizen focus of this article. who performs this act for the public good I will first present a brief discussion of the (Titmuss 1970; Lock 2002: 317–8). Some ob- relevance of the theory of the gift to anthro- servers also argue that the anonymous gift pological studies of organ transplantation, relationship presupposes the anonymity of the together with an overview of kidney trans- object transferred. As Strathern puts it, ‘Organ plantation in the Philippines. Secondly, I will donors can give anonymously because human describe a public event, then relate the story organs are regarded as anonymous: kidneys of a transplantee that will enable us to gain differ in physical condition rather than social a glimpse of the intricacies of this gift rela- identity […]. Such organs or materials as can tionship. Thirdly, I explore two categories of be excised or secreted from the body become recipients’ acts, both of which are important free-standing entities’ (Sharp 1992: 129). components of the gift relationship between Ethnographers have observed, however, the recipient and their donor: ‘acknowledging that the deceased organ donation is not always and repaying the debt’ and ‘taking care of the a ‘free’ gift and the object given is not totally kidney/cherishing the gift’. In doing so, I aim anonymous (Fox and Swazey 1978; 1992; Lock to show that behind these two categories of 2002; Sharp 1995; 2001; 2006). Firstly, in spite acts are two rival conceptions of the gift: one in of the policy of anonymity, some recipients which the gift compels the receiver to give in wish to meet or write letters to the donor return and the other in which the significance family to express their gratitude, while some

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donor families hope to form ‘fictive kinship’ ‘As Marcel Mauss could have foretold, what with recipients (Sharp 2006). Secondly, some recipients believe they owe to donors and the recipients regard transplant organs as still be- sense of obligation they feel about repaying ing attached to the donor; incorporation of the “their” donor for what has been given, weigh inalienable object may lead to ‘transformative heavily on them’ (Fox and Swazey 1992: 40). A experience’ (Sharp 1995; 2006). Some donor transfer of an can also families also hold the view that the life of the lead to a situation in which the donor and the deceased donor somehow persists in the re- recipient are ‘locked in a creditor-debtor vise cipient’s body. that binds them one to another in a mutually It appears then that the predominant logic fettering way’ (1992: 40). of the gift—the nonreciprocal gift of an anony- Although such a picture of live organ trans- mous and alienable object—is haunted by plantation seems to fit well with the Maussian another logic of the gift, which is reminiscent picture of the archaic gift exchange, it leaves of the one which Mauss thought operative in some questions unanswered. Does living do- ‘archaic’ societies. Deceased organ donation nor organ transplantation necessarily lead to may create an enduring bond between the the ‘mutually fettering’ creditor–debtor rela- transacting parties. Unlike transfusion blood, tionship? If not, how this can be explained? the impersonality of which is fostered by the Is this because kidney donation is somehow technological process of separating its com- understood as the ‘free’ gift? Is reciprocity the ponents and storing them (Copeman 2005), only moral principle that governs the gift rela- transplant organs still bear the social identity tionship between the recipient and the donor? of their giver and remain attached to the spe- cific person—at least for some donor families and recipients.2 Kidney transplantation in the What then about living donor organ trans- Philippines plantation? Live donor organs also are ex- pected to be given ‘freely’. The moral concepts Kidney transplantation is a medical procedure of ‘altruism’, which also appear in the Western that is performed on patients who are suf- bioethical discourse on live organ donation, fering from end stage renal disease (ESRD) however, conceal obvious differences between or whose kidneys have irreversibly lost most the of live and deceased organs. A of their functions. Kidney transplantation is live donor organ is predominantly expected considered more cost effective than kidney to be transferred within an interpersonal rela- dialysis and is associated with a better ‘quality tionship of family and friendship, where the of life’. A kidney can be donated either by a anonymity between the donor and recipient is deceased or by a living person. The very first precluded.3 successful kidney transplantation, performed Although the amount and scope of anthro- in 1954, used a kidney donated by the patient’s pological literature on living donor kidney monozygotic twin. Since then, many living do- transplantation is still limited, ethnographic nor kidney transplants have been performed. studies carried out in Western countries have Medical research on the short- and long-term shown that, when an organ is transferred in complications is believed to have shown that such interpersonal relationships, reciprocal donor nephrectomy is a reasonably safe pro- obligation to their donors can be an onerous cedure. burden for recipients (Fox and Swazey 1978; In biomedical and bioethical literature, liv- 1992; Lock 2002). On the basis of their research ing donors are usually classified into ‘(ge- in the United States, Fox and Swazey state: netically) related’ and ‘unrelated’ donors. The

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term, ‘emotionally related donors’, is also used middle class household.4 Owing to financial to designate a specific type of living unrelated hardship, many patients are underdialysed donors, such as spouses, adopted children and and, hence, poorly rehabilitated. In this coun- friends. Many health authorities impose a cer- try, the annual crude mortality rate among tain restriction on the range of kin who are able dialysis patients reaches 80 per cent (Renal to donate an organ; potential donors outside Disease Control Program 2007).5 In this con- this range may donate organs only following a text, it is understandable that many ESRD pa- stricter screening process. tients think staying on dialysis is tantamount In the Philippines, the first kidney trans- to ‘waiting for death’ and desperately seek a plantation took place in 1968 (Dayrit et al. kidney transplant. Such a perception is also 2002: 96, 125). The annual number of kidney held by many kidney transplantees who cel- transplants reached 690 in 2006. In contrast ebrate the anniversary of transplant surgery with most European countries, the major- as their second ‘birthday’ and refer to organ ity of kidney donors are living donors. The donation as the ‘gift of life’. number of deceased donor kidney transplants accounted for only 5.2 per cent (36 out of 690) ‘Tribute to Donors’ and Patricia’s story of all kidney transplants in 2006 (Renal Disease Control Program 2007). Owing to the low rate Together with the Philippine National Trans- of deceased organ donation, living donor kid- plant Games, ‘Tribute to Donors’ is one of the ney transplantation is the first choice for ESRD most important annual events of the KITAP. patients in this country. The event held in June 2004 also marked the The Department of Health defines ‘living- association’s eighteenth anniversary celebra- related donors’ broadly, to include parents, tion. At a large hall in a public hospital, over children, siblings, cousins, nephews, nieces two hundred recipients and donors gathered, and ‘other blood relatives’ (Administrative wearing pink attire, in accordance with the Order no. 124, 2002). It has also ordered an eth- custom of debu—a coming-of-age ceremony ics committee at the transplant centre to screen for eighteen-year-old adolescent women. the relationship between the patients and any Contrary to what some readers may expect potential living unrelated donors in order from the name of the event, honouring of de- to curtail commerce in transplant kidneys. ceased organ donors was not a major compo- Nonetheless, there has been a rapid growth in nent of the ceremonial event. Judging from my the number of living unrelated kidney trans- conversation with the organisers of the event, plants in recent years, the majority of which, neither was the promotion of organ donation presumably, involve some kind of monetary its significant aim; in fact, unlike in the Trans- transaction. The largest group of living-related plant Games, no particular effort was made to donors in the Philippines are siblings of the send out messages on organ donation to the recipient. In 2006, over half of all living-related wider public. Although meanings the event donors were sisters or brothers (50.8 per cent). had for attendants may vary, the highlight of The second largest group were children (14.9 this event, for those whom I talked to, was the per cent), followed by cousins (14.4 per cent) ‘presentation of a token of gratitude’, in which (Renal Disease Control Program 2007). a group of recipients and their living-related The financial agony of patients suffering donors collectively enacted and confirmed the from ESRD forms an important background intimacy between them. to the meaning of kidney transplantation in As the names of eighteen selected kidney the Philippines. The monthly cost of dialysis donors were called out by the host, each of exceeds the monthly income of a typical lower- them came forward and gathered in front of

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a giant cake placed at the side of the stage. a stranger. Worried about the outcome of living After two representatives of the donors lit the unrelated donor kidney transplantation, her eighteen candles on the cake, all of them went father opposed this idea. She also could not find onstage, amid a round of applause. Eighteen another donor candidate among her relatives. recipients followed, each carrying a pink rose. The wretched experience of dialysis eventually Each donor and recipient formed a pair and forced Patricia to accept her brother’s offer. the recipients handed the roses to their donors. She related to me a story of a time when her At this moment, the introduction to Keith brother had a medical examination a month Martin’s hit song, ‘Because of You’, began to after the operation; it showed that Joseph’s play. Touched by the voice of a live singer and serum creatinine concentration had increased the chorus lyrics that suited the occasion—‘Be- slightly above the normal range.7 Patricia said, cause of you. My life has changed. Thank you ‘I felt so guilty. I even told my mother, “I will for the love and the joy you bring … ’—many just return this [kidney] to him”’. According to attendants wept. Some of the donors and re- the doctor, this result was not unusual for the cipients on the stage held onto each other in initial tests. However, Patricia’s concern was tears, and the hall was filled with emotion. only eased when the results of Joseph’s second This continued until the song ended and the test came back as normal. host said jokingly: ‘We put you on the stage to Also relevant to her feeling of guilt was her make you cry!’ brother’s unemployment. Not long after the Among the recipients and donors on the operation Joseph married and became a father, stage were Patricia and her only sibling, her but he had left his former job before the op- younger brother, Joseph.6 Patricia, in her late eration and had had no source of income since thirties, worked as a nurse in the Middle East then.8 Patricia commented that ‘You feel guilty before she was diagnosed with ESRD. As a because you cannot provide what he needs. single mother, she used to send remittances You always have in mind that he saved you’. to her parents and child, saving the rest of Also unemployed and under financial pres- her salary to realise her dream of building a sure arising from the cost of immunosuppres- house of her own. She was forced to give up sants,9 she nevertheless made her best efforts her dream when the doctor told her about her to send him : ‘For me, it is not repaying disease. Learning about Patricia’s condition, what he did for me. Just to make him happy. Joseph, who was working as a bellboy in a In any way, even in a small way, I can make neighbouring country, immediately expressed him happy. Even if it is not as big as what he his wish to become her donor. During an in- did for me’. terview session, Patricia recalled how she felt Taken together, ‘Tribute to Donors’ and Pa- when she saw Joseph for the first time after tricia’s story illustrate what Godelier terms the the operation. She stated in a tearful voice: ‘I ‘duality of the gift relationship’ (1999: 12). On was so grateful. There are patients with many the one hand, in the ceremonial event, Patricia brothers and sisters but none of them wants to and Joseph, together with other recipients donate. And my brother, I did not ask him but and donors, publicly showed a strong sense he volunteered’. of unity and intimacy. On the other hand, It was also apparent from her story that her Patricia’s personal narrative reveals her deep- enormous sense of gratitude was mixed with a seated feeling of guilt. Kidney donation was deep-seated sense of guilt. Before undergoing an extraordinary ‘sacrifice’, involving bod- the operation, Patricia was wary of harming ily harms, risk of complications and the loss Joseph’s body; despite Joseph’s offer, she thus of income. Joseph’s donation of kidney was considered the option of buying a kidney from perceived to create an inherently unrepayable

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debt, which she nevertheless felt compelled to Even though those acts are arguably ‘spon- repay. taneous’ and ‘obligatory’, as Mauss would have said, what the 22 interviewees told me suggests that the way in which this obliga- Acknowledging and repaying the debt tion was felt differed considerably from one Almost all of the 22 interviewees agreed that individual to another. Some recipients seemed kidney donation goes beyond any familial to be comfortable with what they did; fulfill- duties.10 Contrary to what Fox and Swazey ing a reciprocal obligation did not require any (1992) suggest, the receiving of the gift was not more than spontaneous expression of gratitude considered obligatory either; turning down an and renewed love. Others, including Patricia, offer will not offend the potential donor but, stated that they felt ashamed or guilty, because in fact, shows concern for his/her well-being. they were unable to do what they thought they However, this does not mean that the gift is should. What accounts for such differences in free of obligation when it is received. Almost the gift relationship? An examination of the all the 22 interviewees, in one way or another, of the gift exchange in the Fili- testified to their sense of indebtedness and saw pino family helps us to understand why some themselves under obligation to reciprocate. transplantees were more troubled by a recipro- ‘I will acknowledge the debt (utang na loob, cal obligation than others. literally ‘debt of the inside’) for the rest of my life’, transplantees typically stated to express in family and kidney their sense of indebtedness to their living-re- transplantation lated donors. This phrase, ‘to acknowledge the debt’, is widely used in everyday life, together Kinship networks play an extensive role in the with a similar phrase, ‘to repay (bayaran) the circulation and distribution of various kinds of debt’. Whereas the latter expression, when resources in Philippine . Kinship trans- used in a certain context, may have the nega- actions are imagined as consisting of a flow tive connotation of attempting to erase the of gifts. A wide range of and services debt, the former refers to acts that properly flow through kinship network; a predominant show recognition of an unrepayable debt. direction of such gifts is from a parent to a What do kidney transplantees do to ac- child, from an elder sibling to a younger one knowledge and to repay the debt? Showing and from a wealthier sibling to a less wealthy strengthened love, expressions of gratitude, one. This kind of gift, arising from familial and caring for the health of the donor and pay- kinship duties, still leaves the beneficiary with ing special attention to the donors’ children a debt of varying magnitude. Some are were among the things commonly mentioned regarded as being inherently unrepayable, a by those who have received a kidney from paradigmatic example of which is the gift of a family member. Although these could be having been born that a child owes to his or considered ‘countergifts’ in a broad sense, her mother (Cannell 1999; Hollnsteiner 1973; some recipients also made countergifts in a Rafael 1988: 124–134). more tangible form. Depending on the do- Set against this background, the uniqueness nor’s need and the recipient’s capacity, this of a kidney as gift becomes clear. It lies in that ranged from occasional financial aid to the it may flow in the opposite direction, i.e., from provision of a livelihood.11 In short, there a child to a parent, from a younger sibling to was a wide range of goods—‘material’ or an older one and from a less wealthy (poorer) ‘symbolic’—given to acknowledge the debt sibling to a wealthier one (less poor one) and, without erasing it. in many cases, it does. Put rather schematically,

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kidney donations in this case may be perceived the ‘creditor’ solicits, implicitly or explicitly, a by the donors and recipients in the following certain material countergift, to the extent that ways. it is seen as lying beyond the financial capacity Firstly, the gift of a kidney may be regarded of the recipient or as requiring a greater level as arising from the preceding debt, leading to of commitment than the recipient can offer. a relationship within which the recipient and Some KITAP members told me stories they the donor acknowledge mutual indebtedness. heard about the predicament of recipients liv- This idea was found in Richard’s story relating ing under the ‘tyranny of the gift’; donors had to his younger sister’s determination to donate complained that they could no longer work as her kidney. In the beginning, Richard was re- before because of the loss of physical energy; luctant to receive a kidney from her because they had become economically dependent on she was ‘the most frail and delicate’ among recipients. Among my interviewees, one trans- his siblings and because she had just had a job plantee who had received a kidney from her offer. However, she was the most determined younger brother bitterly related how he now among his siblings and strongly insisted on took it for granted that she and her husband becoming a donor. According to Richard, she would provide him with material needs when told him that, as he had helped to meet her he was in need. financial needs so eagerly during her college In short, almost all of the recipients of days, she wanted to help him this time. In such a kidney donated by a family member ac- a narrative, kidney donation is already the knowledge their debt. The fact that the debt ‘return’ of previous gifts, leading to a relation- cannot be cancelled does not mean that ship of mutual indebtedness. they are under no reciprocal obligation, but Secondly, the kidney donation may be per- rather the reverse. Kidney transplantation ceived to create a debtor–creditor relationship is, in this sense, a gift exchange that is never that replaces a previous one. In such cases, to completed. Latent to what some transplants use Bourdieu’s term, the donor accumulates told me, however, was another conception the ‘symbolic capital’ (prestige, fame, etc.) of the gift, which might possibly explain not through the giving of his or her material why some recipients, including those who but through donation of a body part do not or cannot regard a kidney donation (Bourdieu 1990). The expected beneficiary of as a countergift, are nonetheless not always familial gifts in ordinary circumstances is now tormented by their incapacity to repay. also the ‘creditor’. This leads to a situation According to this notion, to remain healthy in which the familial duty to help a younger and to stay alive by taking care of a trans- and/or poorer sibling acquires another di- plant kidney is more important than to give mension of repaying the unrepayable debt.12 countergifts; it is also claimed that being a Some recipients’ countergift-giving to their good steward of a donated kidney is also, in donors—such as provision of capital to start a sense, the truer reciprocal act than to give a small —may be regarded as an at- something in return. Walter, who received a tempt to partially redress this awkward asym- kidney from his mother, stated that, ‘I owe metrical gift relationship. For others, including her my life. I owe her my second life too. And Patricia, this was impossible or inconceivable; she still sends me money to buy medicine’. they are left then with a painful feeling of not But instead of expressing his anguish at be- being able to fulfil their duty to help and care ing in multiple debts which he cannot repay, their donors. he added, ‘To tell the truth, there is only Such a situation may evolve into the ‘tyranny one way to really repay her. To show how of the gift’ (Fox and Swazey 1978; 1992), when you cherish what she has given to you. That

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makes her happy. So you have to take good will realise before long where a transplanted care of it!’ kidney lies through unfamiliar sensations To ‘cherish a gift’ is another duty that beneath their skin. comes with the gift. Failure to act in accord- According to the accounts given to me by ance with this duty, as some recipients stated, many transplantees, they have become accus- may sadden or offend the donor. Rejection tomed to the presence of the new organ. Most episodes were feared not only because they of them, however, have never ceased to feel the may lead to the graft loss but also because it organ’s presence, even many years after the may be interpreted by their donors as a sign operation. They intermittently perceive some of irresponsible stewardship. In order to ob- movements, such as throbbing, hardening, serve how this stewardship is performed by expansion or moderate pain in the location of some of the recipients, including Patricia and the transplanted kidney. They usually inter- Walter, a relationship between the recipient pret these as a sign of vitality of the transplant and the kidney as a gift object will now be organ. Sometimes, these sensations were also explored. said to contain communicative meanings. One interviewee commented that, ‘The pain that you feel in your grafted kidney means that Taking care of a kidney it is telling you, “I need water, please drink ‘Before, you had it at the back. Now you can water!”’ feel that your kidney is here. Something is in These experiences and perceptions were front of you’, said Patricia, recalling the period more or less shared by the recipients of differ- immediately after the transplantation. She also ent categories, including some who had pur- remembered a strange sensation she felt when chased kidneys from unrelated donors. The she was told to stand up by her doctor and idea that a kidney is alive could be regarded took her first steps after the operation. Feel- as the patient’s adaptation to the novel bodily ing as if the transplanted kidney were falling experience. Interestingly, it was also promoted down, she instinctively tried to hold it in place by some nephrologists who perhaps saw it as with her palm. Her doctor assured her that it a useful tip for reminding their patients that would not fall out, yet she continued to hold their body was not completely normal and that up the kidney when she was walking for about it was necessary to comply with the doctor’s a month. instructions. For most of us, the kidney is a silent or- For more than half of the 22 interviewees, gan. We can perceive some of the ‘visceral taking care of a kidney took on another dimen- body’; for example, our stomach grips us sion through the practice of talking to and ca- in hunger and tension in the bladder urges ressing a transplant kidney.13 The metaphorical us to urinate. Yet, some parts of the visceral image underlying this practice was articulated body remain inaccessible to our senses and by Angelita, who had received a kidney from the kidney is such a part (Leder 1990; Kierans her younger brother: 2005). However, kidney transplantation can dramatically change the phenomenological It is as if you were pregnant. You talk to a baby status of this visceral part. A transplant sur- so that it grows well. “Don’t get sick! Don’t geon would place a donated kidney not in raise crea [creatinine]! You get along well there”. Other people may say, “Oh! Are you talking to the position of the two innate kidneys—they your kidney? Maybe you’ve gone mad!” But I are often not removed—but beneath the skin think it is one way of taking care of your kidney. in the abdominal region. When a patient You are like a mother. The baby you have is your wakes up as a new transplantee, he or she kidney inside.

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Although the female transplantees tended to he will grow. Because, you know, your mind is be more explicit about the metaphorical image powerful. What you are thinking and how you of a transplanted kidney as a foetus, it was not are feeling always affect your sense of your body. It is a way of making yourself happy that he is a only the female recipients who talked to and part of me. It is a remembrance between me and touched the surface of the surgical scar. Wal- my brother. Wherever I go, I take him with me. It ter, cited above, regularly talked to his trans- is a reminder of how much you are loved. planted kidney before he went to sleep. Lying on his bed, he would place his palm over it and Patricia’s metaphorical statement—‘you always say, ‘Don’t worry that I don’t always attend to talk to a kidney so that he will grow’—suggests you. I am going to rest now. You also rest if that talking to and caressing the transplant you want to. But please do not stop working kidney was also intended as a form of self-care. completely’. According to Vicente, his brother However, it clearly had additional meaning. told him not to forget to talk to his kidney and The above quotation shows that the transplant he followed his brother’s instruction; he regu- kidney was valued and treasured not only for larly talked to the kidney in the following way: its function—‘Without that, I would not be ‘Don’t forget that I love you. I will take care of here today’—but also for its social origin—‘a you. So you also take care of me’. remembrance between me and my brother’. It is in this sense that the object is treasured for its social identity and is cherished as a symbol Cherishing the gift of her relationship with her donor. Thus, talk- A question that arises at this point is what ing to and caressing a kidney is simultane- kind of meaning this verbal and tactile contact ously the rite of self-care and the cherishing of with a transplant kidney has for these kidney the gift from the other. transplantees. A straightforward answer given The way Patricia referred to her brother by some of them was that talking to and fon- and the kidney suggests that a metaphorical dling a kidney would foster a symbiotic rela- foetus is a metonymical brother. Although tionship between the recipient’s body and the this remains latent in her statement, it found transplant kidney, thereby reducing the risk of a clear expression in the narrative of Estella, acute rejection. The verbal and tactile care of a who had four kidneys in her body, three of kidney is then a sort of preventive and a which had probably already shrunk. Estella, magical form of self-care. the youngest of three female siblings, told However, this does not exhaust the mean- me in a sober voice about the time when a ing the practice of talking to and caressing a transplanted kidney donated by her mother kidney has for recipients. This is articulated was rejected. She frequently failed to comply by Patricia, who also regularly talked to her with the prescriptions due to her financial kidney. Her explanation on the meaning of the problems. Soon after she went back on di- practice was as follows: alysis, Estella told her family that she never wanted to go back on dialysis again. As she I do that because of, you know, the joy of, you was lying on the bed in her room alone, her know, remembering that it is given to me by my two older sisters came in and told her that brother. I should take care of it like my brother one of them would be her donor and the took care of me. He suffered very much. He gave other would go abroad to work, leaving her it to me without asking for anything in return. husband and children behind, in order to What he has given to me is a part of me. I have to cherish it. It is a gift from him. Without that, I send her remittances. Estella said that she would not be here today. It is just like cherishing talked to her kidneys as though she had fam- a baby. You always talk to him so that, you know, ily inside her body.

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According to Strathern, unlike the Euro- reluctantly agree, so too does your kidney. It’s American bodies and body parts imagined like it is brought into an alien place’. as things ‘owned’ by the self, the Melanesian In The Gift, Mauss argued that the ‘archaic’ body is imagined as a register of the effects of gift is simultaneously attached to the giver historical social interactions and a microcosm and possesses a spirit or soul that animates of relationships. ‘In the Melanesian image, a the object with life and seeks ‘to return to its series of events is being revealed in the body, birthplace, to the sanctuary of the forest and the actions of social others: what people have the clan, and to the owner’ (Mauss 1990: 16). or have not done to or for one’ (Strathern For Mauss, it was this spirit, hau, or the be- 1988: 132). When Patricia says ‘he is a part of lief in it, that ultimately forced the gift to be me’ and Estella says ‘my family is inside my repaid in the ‘archaic’ gift exchange. Such a body’, their bodies appear rather like the body ‘spiritual explanation’ on reciprocity and obli- of the ‘Melanesian’. It is important to note that gation to repay received much scholarly com- a kidney as gift object does not seem to stand ment and criticism (Levi-Strauss 1987; Sahlins merely for the creditor–debtor relationship 1974; Godelier 1999). However, an interesting that it created. Talking to and caressing the comparison may be drawn between Mauss’s kidney is often said to be a joyful and pleasur- characterisation of the ‘spirit’ of an archaic gift able experience. This is because it stands for and that of the transplant kidney. the relationship of which it is a product. As On the one hand, there is a remarkable com- Patricia commented, ‘It is a reminder of how monality between the ‘archaic’ gift and the much you are loved’. transplant kidney; both of them are not only attached to the person but are also personi- fied; they are seen as being animated, having The spirit of the transplant kidney its own will and moving on its own accord. On Coexisting with the idea that a verbal and the other hand, there is an important differ- tactile care of a kidney fosters a symbiotic re- ence between them. Unlike the spirit animat- lationship with the body was a that, if a ing the ‘archaic’ gift, the spirit animating the kidney is donated wholeheartedly, it functions wholeheartedly donated kidney does not so better after transplantation, an idea to which much seek to return or send its equivalent to most of the interviewees subscribed. Asked the original owner as to settle into the body to why this is so, some gave a more ‘secular’ which it was sent. explanation than others. For example, Patri- If we return to Walter’s statement that the cia explained, ‘It is probably psychological. If best way to repay the unrepayable gift is by you know that it is not given from the heart, taking care of the kidney, a different view may your thinking also will be negative…That af- emerge; the spirit of the gift that seeks to settle fects your health in general and the way your in the recipient’s body is, indeed, also the one body accepts the kidney’. More commonly, that is seeking to send some kind of return to transplantees gave me a more ‘spiritual’ or the place of origin, i.e., happiness to the donor. ‘magical’ explanation. According to them, re- This does not mean, however, that the spirit flecting the intention of the original owner, of archaic gift and the spirit of the transplant a kidney given from the heart seeks to settle kidney are identical, after all, since the latter into the recipient’s body. Walter commented embodies the conception of gift, according to that, ‘If the owner of the kidney is willing and which keeping for oneself and giving in re- says ‘Doctor, I am willing’, it is as though the turn are not two different acts but merge into kidney also accepts that (decision) willingly: the single act of taking care of the kidney and “I will get along well in your body!” If you cherishing the gift.

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Conclusion trap of being caught up in endless recipro- cal obligation while other recipients are In this article, I explored some facets of the obliviously torn apart between the two rival gift relationship created by living-related do- principles. nor kidney transplantation between Filipino Finally, I should take note that this concep- family members. What the ethnographic ma- tion of the gift is not to be conflated with that terials show is that, as previous studies on of ‘free’ and ‘altruistic’ gift. ‘Altruism’ rests on deceased organ transplantation in Western a relationship between mutually independent societies suggest, live organ transplantation is individuals. However, the principle of gift also a locus in which conflicting conceptions which we have seen rests on a relationship of and rival principles of gift simultaneously mutual dependence: a relationship in which operate. what is for the self and what is for the other are On the one hand, live kidney transplanta- not mutually exclusive. In such a social con- tion between Filipino family members shares text, a claim that the recipient’s act of cherish- certain aspects with the ‘archaic’ gift exchange ing the gift could also be the ultimate reward depicted by Mauss and his successors. Even for the donor cannot be dismissed as fanciful. though kidney donation is viewed by the It is also this logic based on a relationship of recipients as lying beyond any obligation, mutual dependence that the ‘spirit’ animating and there is no obligation to receive when it the donated kidney seems to embody. is offered, there is a reciprocal obligation. A Yosuke Shimazono is a DPhil student based at the kidney transferred from one family member to Institute for Social and , another is not an anonymous and impersonal Oxford University. Yosuke’s research investigates object. It remains attached to the donor, carries kidney transplantation in the Philippines. He has along the memory of the donor’s sacrifice and also prepared and published reports on the topic for compels a recipient to reciprocate. the World Health Organisation. On the other hand, discernible from the words and actions of some of the recipients is another conception of gift. Following this Notes conception, good stewardship over the thing given is more important than to give equiva- 1. For the reason why the idea of a ‘free gift’ can be called ‘modern’, see Jonathan Parry (1986). lently moreover, it is also claimed that the best 2. For a more nuanced discussion on blood trans- and only possible way to reward the donor is fusion, see Copeman (2005). to take care of the transplant kidney and to 3. Unlike deceased organs, it is rare for the gift of cherish the gift. live kidney to be offered to a stranger; ‘good As ethnographic research on living donor Samaritan’ donors tend to raise suspicion and organ transplants is still in its infancy, I shall caution rather than admiration. In the United Kingdom, it is only recently that such donation refrain from a premature cross-cultural com- has begun to be accepted (BBC 2006). parison. However, what we have seen in this 4. The monthly cost of the standard treatment paper seems to partly explain why a transfer for a dialysis patient ranges between P30,000- of the kidney between Filipino family mem- 50,000. The national average family income bers does not always lead to the ‘mutually is P14,416/month (National Statistics Office. fettering’ debtor–creditor relationship. The Available from http://www.census.gov.ph/, last accessed on April 30, 2008). The majority of alternative principle of the gift, which places the cost is not covered by the national health- stewardship over reciprocity, cherishing of care insurance program. Therefore, majority of the gift over repaying of the debt, seems to patients rely on financial assistances from their allow some Filipino recipients to evade the kinspersons and charity organisations.

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5. The crude mortality rate was calculated by and the Morality of Exchange, (ed.) J. Parry and the author based on data given in the national M. Bloch (Cambridge: Cambridge University renal registry (Renal Disease Control Program Press), 1–32. 2007). In most developed countries, it usually Bourdieu, P. (1990), The Logic of Practice, (trans.) ranges between eight to fifteen per cent. Richard Nice (Cambridge: Polity Press). 6. Pseudonyms are used in this article. Cannel, F. (1999), Power and Intimacy in the Chris- 7. The value of serum creatinine concentration tian Philippines (Cambridge: Cambridge Univer- is used to measure the functioning of the kid- sity Press). neys. Normal serum creatinine concentration Carrier, J. (1994), Gifts and : Exchange is < 1.6 mg per dl in men, and < 1.4 mg per dl and Western Capitalism Since 1700 (London: in women. Routledge). 8. He was able to find a job abroad by the time I Copeman, J. (2005), ‘Veinglory: exploring processes last interviewed Patricia. of blood transfer between persons’, Journal of 9. Some Filipino transplantees do not ‘comply’ the Royal Anthropological Institute 11, no. 3: with prescription regimens because they can- 465–485. not afford all the immunosuppressants. This Dayrit, C. S., Ocampo, P. D. and de la Cruz, E. R. was not the case with Patricia although she (2002), History of Philippine Medicine 1899–1999: seemed to have sometimes struggled to do so. With Landmarks in World Medical History (Pasig 10. This does not mean that there are no cases City: Anvil). where a potential donor feels pressured to do- Deguchi, A. (2002), ‘Organ Transplantation, nate. Anthropological Gift Theories, and the Self 11. Although some Westerners may regard such a Who Turns into the Other to Oneself’, The countergift of money with unease due to the Japanese Journal of 66, no. 4: 439–459 culturally specific symbolism of money (Bloch (in Japanese). and Parry 1989), this was not the case in the Fox, R. and Swazey, J. P. (1978), The Courage to Fail: Philippines. A Social View of Organ Transplants and Dialysis 12. There are other factors that come into play. (Chicago: University of Chicago Press). Firstly, transplantees may or may not be seen -----. (1992), Spare Parts: Organ Replacement in Amer- as still ill people who need special support and ican Society (Oxford: Oxford University Press). are exempted from their familial duties. Sec- Godelier, M. (1999), The Enigma of Gift, (trans.) ondly, kidney donation may result in a change Nora Scott (Cambridge: Polity Press). in the financial circumstances of both parties. Hollnsteiner, M. R. (1973), ‘Reciprocity in the For example, the donor may lose his or her lowland Philippines’, in Four Readings in Philip- income because of the kidney donation, or the pine Values,, (ed.) F. Lynch and A. de Guzman recipient may be transformed from an almost II (Quezon City: Ateneo de Manila University dying person to an almost normal person, with Press), 69–92. his or her own source of income. Kierans, C. (2005), ‘Narrating Kidney Disease: The 13. Francisco Valera, who had undergone a de- Significance of Sensation and Time in the Em- ceased liver transplantation, also talks of his plotment of Patients Experience’, , Medi- ‘gentle touch’ (Valera 2001). Lock cites an ex- cine and Psychiatry 29, no.4: 341–359. ample of an American recipient of a kidney and Lévi-Strauss, C. (1987), Introduction to the Work of liver from a deceased donor who also felt as if Marcel Mauss, (trans.) Felicity Baker (London: she were pregnant (2002: 328). Routledge and Kegan Paul). Lock, M. (2002), Twice Dead: Organ Transplants and the Reinvention of Death (Berkeley, Los Angeles, References and London: University of California Press). Mauss, M. (1990), The Gift: The Form and Reason for BBC News (2006), ‘Strangers allowed to give Exchange in Archaic Societies, (trans.) W. D. Hall organs’, < http://news.bbc.co.uk/1/hi/ (London and New York: Routledge). health/4942732.stm> (accessed 31 August Parry, J. (1986), ‘The Gift, the Indian Gift and the 2006). “Indian Gift”’, Man 21, no. 3: 453–473. Bloch, M. and Parry, J. (1989), ‘Introduction: Rafael, V. (1988), Contracting : Money and the Morality of Exchange’, in Money Translation and Christian Conversion in Tagalog

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Society under Early Spanish Rule (Quezon City: Simmons, R. G., Marine, S. K. and Simmons, R. L. Ateneo de Manila University Press). (1987), Gift of Life: The Effect of Organ Transplan- Renal Disease Control Program (2007), Philippine tation on Individual, Family, and Social Dynamics Renal Disease Registry: Report for 2006 (Quezon (New Jersey: Transaction Books). City: Renal Disease Control Program). Strathern, M. (1988), The Gender of the Gift, Problems Sahlins, M. (1974), Stone Age (London: with Women and Problems with Society in Tarvistock Publications). Melanesia (Berkley, Los Angeles: University of Sharp, L. A. (1995), ‘Organ Transplantation as California Press). a Transformative Experience: Anthropological -----. (1992), Reproducing the Future: Anthropology, Insights into the Restructuring of the Self’, Kinship and the New Reproductive Technology Quarterly 9, no. 3: (Manchester: Manchester University Press). 357–389. Titmuss, R. M. (1970), The Gift Relationship: From -----. (2001), ‘Commodified Kin: Death, Mourning, Human Blood to Social Policy (London: George and Competing Claims on the Bodies of Organ Allen & Unwin Ltd). Donors in the United States’, American Anthro- Weiner, A. (1992), Inalienable Possessions: The pologists 103, no. 1: 112–133. Paradox of Keeping-While-Giving (Berkeley, -----. (2006), Strange Harvest: Organ Transplants, Los Angeles: University of California Press). Denatured Bodies, and the Transformed Self Valera, F. J. (2001), ‘Intimate Distances: Fragments for a (Berkeley, Los Angeles, and London: University Phenomenology of Organ Transplantation’, Journal of California Press). of Consciousness Studies 8, no. 5–7: 259–271.

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